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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> (Ji sconmn Power atrib Ohl.Corhpor Li Zoning Stat UP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) / CSIVI 4 9 Nori Blimor�eLahe, m )sn,WI53718- 1 $eed <br /> a r. ce(# ) <br /> Ii8ME PHONE CELL PHONE E-MAIL ADDRESS <br /> 3166 briancoo ®allwntienels.com <br /> Si Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION d includes dimensions <br /> AGENT NAME CONTACTOR NAME <br /> 1rtQn Ccr�ke gne.r ri,me- Si Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS well/septic <br /> *942 ivo4 B)ltmorGLane. VP IYtorrts Stnazt' <br /> (City,State,Zip) (City.State,Zip) Setbacks <br /> me lson, WI 531/8-at' F Idk Lac. . <br /> PHONE PHONE ❑ Si Plan royal from <br /> 9.5f3456 720--90/1-81$2 pli a township. <br /> E-MAILADDRE S E-MAIL ADDRESS <br /> I)riRYrAW e®ellta ehinr.4911 Fl or plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCE NUMBER: CUR ENT OO,V�IN A REAGE: P P y <br /> ❑ PARCEL , 0501.092.016-D 4.) ,93' fr tage drawn to scale. <br /> NUMBER '"""'1111 T <br /> TOWNSHIP. SECTION: <br /> D►" n q '/a: ma wh: Ng Driveway permits <br /> ADDRESS: (state,county,town) <br /> heeds to be as'sisned <br /> ❑ Sanit- permits <br /> CS`���� LOT SUBDIVISION BLOCK/LOT <br /> (p • c,private) <br /> PROPOSED PROJECT INFORMATION AFF REVIEW <br /> PROJ�jCT DESCRIP ION: <br /> toe�j•1C41 SUdsf(1 ;0/I / j ',4 h O II ning District <br /> ®This project is a new building or structure. <br /> Permitted Use? <br /> ❑This project is an to an existing building or structure. <br /> SANITARY SERVICE: NIA PERMIT NUMBER: NA ❑ Rural Address <br /> ❑SEWER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> /gg, ' ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: Coo ❑ ErosionControl permit <br /> i`L/11 <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> Goo <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ --► ♦ ita qQ and available options. <br /> (Please round to nearest dollar) l3) / !� <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? X)Yes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes XI No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ig Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes )1:1 No <br /> 5. Is this project associated with rezon: CUP/variance(petition/appeal# %.Z ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes No ❑Don't know <br /> 7. Is this to correct a violation? Li Yes ®No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />